So there you are seeing patients like any other day, when you get a notification vibration for an email on your smart phone. It's from someone at an another agency you used to work for telling you that they are still billing Medicaid for services under your provider ID number, even though you haven't worked there in a while. You stare at your phone and wonder what this means, and how to proceed...
A friend of mine recently came to me with these facts, and it was giving him some sleepless nights for some time. He had heard from former front office staff at a different healthcare employer that his provider license number was allegedly being used to bill Medicare/Medicaid despite the fact that they haven’t worked for that former employer for several months.
This unfortunate scenario can be a big problem. You didn't ask for it or do anything wrong, but not only do you need to protect your license, but you also need to ensure that you are not implicated in a Medicare/Medicaid or private insurance fraud scheme, which has major consequences under state and Federal False Claims Acts and other healthcare laws.
SIMPLE STEPS TO TAKE IF YOU HAVE REASON TO BELIEVE YOUR LICENSE IF BEING FRAUDULENTLY USED FOR INSURANCE BILLING PURPOSES:
1) Find out if your provider license number is actually being used to bill Medicaid (the state-run public medical assistance programs). Don't let your imagination go wild. Call your state’s Medicaid provider help line immediately and find out for certain. Or, for faster service, you can also contact the state’s Medicaid attorneys or the state Attorney General’s office directly.
Ask them for a list of all billing done under your name and license for whatever time period you believe your provider license number was being used.
You can start with this list, which has the state-by-state fraud and abuse reporting contacts numbers, forms, and email addresses. (https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforConsumers/Downloads/smafraudcontacts-april2013.pdf)
2) Similarly, you need to find out if your provider license number is being used to bill Medicare (the Federal healthcare public assistance program).
To do this, the best route is to call the Medicare Provider Help Line: .
You can also find more contact information at the Medicare Billing webpage.(http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/)
If that contact page is not yielding results for you, you can also call the following numbers and they will suggest other ways to get your Medicare billing:
HHS Office of Inspector General
Centers for Medicare & Medicaid Services
3) Contact any private insurance vendor that might have accepted your provider license number and also ask them for billing that is being attributed to you.
4) If in fact your license number is being used fraudulently, this is a serious offense and you must take steps to protect your license and yourself from liable for fraud. Contact a healthcare attorney immediately for further advice. They may advise you on potential legal actions that you can take, such as to contact the insurance provider, state, or Federal government for self-reporting. Or they may give you other legal advise, including launching a qui tam* lawsuit against the Medicare/Medicaid fraudster.
A qui tam lawsuit is a type of civil lawsuit brought under the False Claims Act, a law that rewards “whistleblowers” if the case recovers fraudulent Medicare/Medicaid reimbursement funds for the government.
You might be entitled to between 15 to 30 percent of the recovery and fines, which can be millions of dollars.
*Qui tam is an abbreviation of the Latin phrase qui tam pro domino rege quam pro se ipso in hac parte sequitur, meaning "[he] who sues in this matter for the king as well as for himself."